After training in NSW, further training in Urologic Oncology (Urologic cancer surgery) was undertaken at the University of Miami Miller School of Medicine. Dr Arianayagam completed a two year fellowship accredited by the Society of Urologic Oncology.

The Chairman of the department at time was Dr Mark Soloway, an acknowledged leader in surgery for bladder cancers and hence, Dr Arianayagam has had a very large experience in treating patients with these tumours. Since training in the USA Dr Arianayagam performs all bladder removal procedures with the the da Vinci robot.

When the bladder is removed, the urine needs to be diverted either with an ileal conduit where the patient wears a “bag” or with a neobladder which is an internal reservoir. The neobladder has excellent functional outcomes as patients can pass urine normally and do not have to wear any external devices (like the stoma bag for urine). In selected men, the nerves to the penis may be preserved facilitating sexual function.

Dr Arianayagam also performs the diversion using the robot in a technique called intracorporeal. The entire diversion is made internally rather than making a larger incision to complete the diversion which is the more common technique. Intracorporeal diversion is far more technically challenging method of urinary diversion.

While at the University of Miami, Dr Arianayagam was also involved in writing guidelines for the treatment of bladder cancer. This was a book written for the International Consultation on urologic diseases. The recommendations from this book were presented at the European Association of Urology international meeting in 2011 in Vienna, Austria.

At the University of Miami Dr Arianayagam had the privilege of learning from Dr Gaetano Cancio, who is a transplant surgeon who works closely with the Urology department. During this period Mohan learned how to perform kidney removal for very large tumours using liver transplant techniques. Many of these tumours are unique in that they spread into the veins draining the kidney (renal vein) as well as into the major vein that drains blood from the lower body and gut into the heart (inferior vena cava). This is a particularly challenging operation as the tumour in the vein (thrombus) can extend from the kidney up to the heart. These procedures are only performed at a few large centres due to the complex nature of the surgery and the intensive care support that is needed.

In addition to these procedures, there was extensive exposure to all aspects of cancer surgery. There was a University Clinic where tremendous experience was obtained in looking after patients with urologic cancers. Patients were cared for using a multidisciplinary approach, where case conferences were held between all the doctors involved in cancer care to obtain the best outcomes for patients (multidisciplinary team). The opportunity to discuss problems with medical oncologist (doctors who give chemotherapy to treat cancer) and radiation oncologists (doctors who treat cancers with radiation) was invaluable and is considered the standard of care. Dr Arianayagam is the coordinator of the multidisciplinary team for the department of Urology at Nepean hospital.

Procedures performed:

1. Radical nephrectomy (removal of the kidney)
2. Partial nephrectomy (removal of part of the kidney)
3. IVC thrombectomy (removal of kidney with tumour in the veins)
4. Adrenalectomy (removal of adrenal gland)
5. Radical cystectomy (removal of bladder)
6. Neobladder urinary diversion (new bladder made from small bowel)
7. Retroperitoneal lymph node dissection (removal of cancerous lymph nodes)
8. Testicular cancer surgery

Dr Arianayagam performing open surgery